Chapter 7 Flashcards
A left ventricular ejection fraction of less than what value is the threshold for diagnosis of
HF with reduced ejection fraction?
A. 20% (0.20)
B. 30% (0.30)
C. 40% (0.40)
D. 50% (0.50)
Option C: Correct. The accepted threshold for defining HFrEF is less than 40% (0.40).
What is the most common etiology of heart failure?
A. Ischemic
B. Idiopathic, unknown cause
C. Viral cardiomyopathy
D. Drug-induced
Option A: Correct. Ischemic etiology, resulting from coronary artery disease, is the most
common cause of HFrEF, occurring in up to two-thirds of cases.
What is the medical term for the symptom requiring a person to sleep more upright in
order to feel comfortable breathing?
A. Orthopnea
B. Hepatojugular reflux
C. Paroxysmal nocturnal dyspnea
D. Pulmonary congestion
Option A: Correct. Orthopnea refers to shortness of breath with a recumbent position that
subsides when sitting up.
Which of the following guideline-directed medical therapies is not associated with an
improvement in survival in HFrEF?
A. Spironolactone
B. Sacubitril and valsartan
C. Hydralazine and isosorbide dinitrate
D. Ivabradine
Option D: Correct. Ivabradine was only shown to improve risk of hospitalizations but not
mortality in its pivotal HFrEF trial.
A 64-year-old Hispanic man with HFrEF is currently receiving GDMT including
losartan, carvedilol, and torsemide. The patient is NYHA FC III. Vitals and laboratory
values are within normal limits. What additional therapy would be most appropriate to
initiate in this patient to further reduce morbidity and mortality?
A. Eplerenone
B. Digoxin
C. Hydralazine and isosorbide dinitrate
D. Metoprolol succinate
Option A: Correct. Addition of a MRA to initial RAAS inhibitor and β-blocker therapy is
recommended to further reduce the risk of morbidity and mortality.
A 66-year-old woman presents to clinic for HF follow-up. She has no complaints other
than noticing increasing lower extremity edema despite being compliant with her furosemide regimen of 20 mg twice daily. She also reports a reduction in urine output.
Vitals and laboratory values are within normal limits. Which of the following interventions is most appropriate at this time?
A. Switch furosemide to torsemide 20 mg twice daily
B. Add metolazone 10 mg once daily
C. Increase furosemide to 30 mg twice daily
D. Switch furosemide to hydrochlorothiazide 25 mg once daily
Option A: Correct. When loop diuretic therapy is escalated, the dose should be doubled.
Furosemide is half as potent as torsemide, so giving the same mg dose of torsemide is
equivalent to doubling the mg dose of furosemide.
A 68-year-old woman returns to clinic after having a follow-up echocardiogram for
evaluation of cardiac structure and function on optimal HF medications to assess next
steps. Her echo reveals an LVEF of 30% to 35% (0.30-0.35), which is only marginally
improved compared to her baseline echocardiogram of 25% to 30% (0.250.30). She is NYHA FC II by symptoms today. Her current cardiac medications include enalapril 10mg twice daily, carvedilol 25 mg twice daily, digoxin 0.125 mg once daily, and spironolactone 25 mg once daily. She is euvolemic. Vitals: BP 122/74 mm Hg, HR 58beats/min, weight 82 kg (180 lb; dry weight). What is the most appropriate treatment plan for the patient at this point?
A. Increase carvedilol to 50 mg twice daily
B. Switch enalapril to sacubitril/valsartan
C. Add candesartan
D. Increase digoxin to 0.25 mg daily
Option B: Correct. Switching to sacubitril/valsartan is correct based on the latest
treatment guidelines for heart failure, which recommend switching to an angiotensin
receptor neprilysin inhibitor in the setting of symptomatic HFrEF in a patient currently
tolerating an ACE inhibitor or ARB.
A 73-year-old man is admitted to the hospital presenting with peripheral and sacral
edema and hepatomegaly. Patient is having difficulty concentrating and peripheral pulses
are diminished. Urinary output is diminished. Pertinent values: PCWP = 32 mm Hg (4.3
kPa), cardiac index (CI) = 1.7 L/min/m 2 (0.028 L/s/m 2 ). Based on his presentation, what
hemodynamic subset is he in?
A. I
B. II
C. III
D. IV
Option D: Correct. Subset IV are patients who are cool and wet. This patient meets the
criteria both clinically and via the hemodynamics obtained (CI < 2.2 L/min/m 2 [0.037
L/s/m 2 ] and PCWP > 18 mmHg [2.4 kPa]).
Which of the following diuretic combinations provides sequential blockade of sodium
reabsorption in the nephron to overcome diuretic resistance in HF?
A. Hydrochlorothiazide and eplerenone
B. Torsemide and ethacrynic acid
C. Furosemide and spironolactone
D. Bumetanide and metolazone
Option D: Correct. Metolazone is added when volume retention does not respond to loop
diuretics.
- Which of the following statements is most appropriate for patient counseling on
nonpharmacologic management of HF?
A. Heavy weightlifting is recommended for physical activity.
B. Fluid intake should be restricted no more than 1 L/day.
C. Lower dietary sodium intake to no more than 3 g/day.
D. Daily weight should be checked each evening prior to sleeping.
Option C: Correct. Current recommendation for patients with persistent volume overload
is to limit sodium intake to approximately 3 g/day.
A 70-year-old white man presents to the emergency department in severe respiratory distress.
Past medical history includes coronary artery disease, HFrEF, hypertension, and COPD. The
patient doesn’t manifest signs of volume overload and only endorses minimal pedal edema.
Which test would be most appropriate to obtain to help determine a diagnosis?
A. Serum sodium
B. BNP level
C. Swan-Ganz catheter placement
D. ECG
Options B: Correct. Natriuretic peptide levels are useful for differentiating dyspnea due
to HF from other causes.
A 70-year-old white man presents to the emergency department in severe respiratory distress.
Past medical history includes coronary artery disease, HFrEF, hypertension, and COPD. The
patient doesn’t manifest signs of volume overload and only endorses minimal pedal edema.
The patient is treated for the acute respiratory event and is being prepared for discharge
home. You are consulted as the pharmacy clinician on the cardiology team to optimize
his HF regimen. His current HF medication regimen: aspirin 81 mg once daily, lisinopril
20 mg once daily, metoprolol succinate 200 mg once daily, and furosemide 40 mg twice
daily. His BP is 122/75 mm Hg and HR 79 beats/min (in normal sinus rhythm). Pertinent
laboratory values include sodium 135 mEq/L (mmol/L), potassium 5.3 mEq/L (mmol/L),
and SCr 2.1 mg/dL (186 μmol/L). Which therapy is most appropriate to add at this time
to further improve prognosis?
A. Spironolactone
B. Sacubitril/valsartan
C. Hydralazine and isosorbide dinitrate
D. Ivabradine
Option D: Correct. Ivabradine is indicated in patients with symptomatic HFrEF on
maximally tolerated β-blockade, in normal sinus rhythm, and resting HR greater than 70
beats/min, to further reduce the risk of HF hospitalizations.
An 81-year-old woman presents to the clinic today with a chief complaint of increasing
fatigue and swelling in her legs. She used to be able to walk without limitations, but for the
last month now gets short of breath when walking her dog after five to six blocks. She also
noticed that her legs get progressively swollen throughout the day. She denies trouble
sleeping and uses one pillow. She denies any fever, cough, chills, or nausea. Past medical
history is significant for hypertension × 25 years, recurrent persistent nonvalvular atrial
fibrillation × 15 years, and osteoporosis × 10 years.
Physical examination reveals the following: BP 150/96 mm Hg, pulse 110 beats/min, Wt 130
lb (59 kg)
Lungs: decreased breath sounds at the bases, no wheezes or rhonchi
CV: + JVD, tachycardic, irregularly, irregular rhythm, +S3, PMI nondisplaced
GI: +BS, soft, NTND, no hepatomegaly
Extr: 1+ pitting edema to the knees, pulses intact, skin warm
ECG: HR 110 beats/min, irregularly, irregular rhythm, LVH, no acute ST–T wave changes
ECHO: EF 35% (0.35)
CXR: cephalization
Laboratory values:
Sodium: 140 mEq/L (mmol/L)
Potassium: 5.1 mEq/L (mmol/L)
Magnesium: 1.9 mEq/L (0.95 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 µmol/L)
BNP: 560 pg/mL (ng/L; 162 pmol/L)
Current medications:
Apixaban 2.5 mg twice daily
Amlodipine 5 mg daily
Metoprolol succinate 25 mg once daily
Calcium carbonate 500 mg three times daily
Vitamin D 800 IU once daily
Which of the following is the correct classification of this patient by NYHA function
class?
A. FC I
B. FC II
C. FC III
D. FC IV
Answer: B
Option A: Incorrect. The patient has symptoms and so cannot be FC I (asymptomatic
with no limitations in daily activities).
Option B: Correct. The patient has slight limitation in daily activities.
Options C: Incorrect. The patient does not present with marked limitations in daily
activities (ie, is able to walk five to six blocks before developing symptoms).
Option D: Incorrect. The patient does not present with symptoms at rest..
An 81-year-old woman presents to the clinic today with a chief complaint of increasing
fatigue and swelling in her legs. She used to be able to walk without limitations, but for the
last month now gets short of breath when walking her dog after five to six blocks. She also
noticed that her legs get progressively swollen throughout the day. She denies trouble
sleeping and uses one pillow. She denies any fever, cough, chills, or nausea. Past medical
history is significant for hypertension × 25 years, recurrent persistent nonvalvular atrial
fibrillation × 15 years, and osteoporosis × 10 years.
Physical examination reveals the following: BP 150/96 mm Hg, pulse 110 beats/min, Wt 130
lb (59 kg)
Lungs: decreased breath sounds at the bases, no wheezes or rhonchi
CV: + JVD, tachycardic, irregularly, irregular rhythm, +S3, PMI nondisplaced
GI: +BS, soft, NTND, no hepatomegaly
Extr: 1+ pitting edema to the knees, pulses intact, skin warm
ECG: HR 110 beats/min, irregularly, irregular rhythm, LVH, no acute ST–T wave changes
ECHO: EF 35% (0.35)
CXR: cephalization
Laboratory values:
Sodium: 140 mEq/L (mmol/L)
Potassium: 5.1 mEq/L (mmol/L)
Magnesium: 1.9 mEq/L (0.95 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 µmol/L)
BNP: 560 pg/mL (ng/L; 162 pmol/L)
Current medications:
Apixaban 2.5 mg twice daily
Amlodipine 5 mg daily
Metoprolol succinate 25 mg once daily
Calcium carbonate 500 mg three times daily
Vitamin D 800 IU once daily
Which of the following is the correct classification of this patient by HF stage?
A. Stage A
B. Stage B
C. Stage C
D. Stage D
Answer: C
Options A: Incorrect. Stage A is for patients at risk of HF but have no evidence of
structural heart disease. This patient has a depressed LVEF.
Option B: Incorrect. Stage B is for patients with structural heart disease but have yet to
develop symptoms of HF. This patient is symptomatic.
Option C: Correct.
Option D: Incorrect. This patient is not at end stage as no history is provided that would
suggest they are refractory to medical therapy.
An 81-year-old woman presents to the clinic today with a chief complaint of increasing
fatigue and swelling in her legs. She used to be able to walk without limitations, but for the
last month now gets short of breath when walking her dog after five to six blocks. She also
noticed that her legs get progressively swollen throughout the day. She denies trouble
sleeping and uses one pillow. She denies any fever, cough, chills, or nausea. Past medical
history is significant for hypertension × 25 years, recurrent persistent nonvalvular atrial
fibrillation × 15 years, and osteoporosis × 10 years.
Physical examination reveals the following: BP 150/96 mm Hg, pulse 110 beats/min, Wt 130
lb (59 kg)
Lungs: decreased breath sounds at the bases, no wheezes or rhonchi
CV: + JVD, tachycardic, irregularly, irregular rhythm, +S3, PMI nondisplaced
GI: +BS, soft, NTND, no hepatomegaly
Extr: 1+ pitting edema to the knees, pulses intact, skin warm
ECG: HR 110 beats/min, irregularly, irregular rhythm, LVH, no acute ST–T wave changes
ECHO: EF 35% (0.35)
CXR: cephalization
Laboratory values:
Sodium: 140 mEq/L (mmol/L)
Potassium: 5.1 mEq/L (mmol/L)
Magnesium: 1.9 mEq/L (0.95 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 µmol/L)
BNP: 560 pg/mL (ng/L; 162 pmol/L)
Current medications:
Apixaban 2.5 mg twice daily
Amlodipine 5 mg daily
Metoprolol succinate 25 mg once daily
Calcium carbonate 500 mg three times daily
Vitamin D 800 IU once daily
Which of the following is the most appropriate acute intervention for this patient?
A. Add furosemide
B. Switch metoprolol succinate to tartrate
C. Add sacubitril/valsartan
D. Switch apixaban to warfarin
Answer: A
Option A: Correct. The patient is presenting with acute signs and symptoms of volume
overload.
Options B: Incorrect. Metoprolol succinate is the approved form for HFrEF.
Option C: Incorrect. Sacubitril/valsartan is currently recommended in patients who are
already on and tolerating an ACE inhibitor; this patient has yet to be initiated on an ACE
inhibitor. The potassium is also slightly elevated at 5.1 mEq/L (mmol/L).
Option D: Incorrect. There is no specific preference for warfarin over a NOAC for
patients with HFrEF and nonvalvular atrial fibrillation, although anticoagulation is
indicated.
